Pancreas-sparing distal duodenectomy for infrapapillary neoplasms.

INTRODUCTION: For neoplasms that arise in the third and fourth parts of the duodenum (D(3), D(4)), a duodenectomy that preserves the pancreas can provide adequate tumour clearance while avoiding the additional dissection and risk of the common alternative, pancreatoduodenectomy. PATIENTS AND METHODS: Pancreas-sparing distal duodenectomy (PSDD) was performed in 14 patients with infrapapillary duodenal neoplasms between 1991-2002, and the clinical outcome is reviewed. The operation entails careful separation of the lower pancreatic head from D(3), complete mobilisation of the ligament of Treitz and end-to-end duodenojejunal anastomosis 1-3 cm below the major duodenal papilla. RESULTS: There were 9 men and 5 women of median age 56 years, who presented with iron-deficiency anaemia (n = 8), gastric outlet obstruction (n = 4), anaemia and gastric outlet obstruction (n = 1), epigastric pain or mass (1 each). There were 11 malignant neoplasms (adenocarcinoma 5, stromal tumour 4, recurrent seminoma 1, plasmacytoma 1), 2 benign neoplasms (villous adenoma, lipoma) and 1 patient with steroid-induced ulceration. In addition to D(3) and D(4), resection included the distal part of D(2) in 5 patients, while 4 required concomitant partial colectomy. Median operation time was 240 min and median blood loss 1197 ml, being greater for malignant than benign lesions (1500 ml versus 700 ml). There was one death from gangrenous cholecystitis, one early re-operation for anastomotic bleeding and one late re-operation for delayed gastric emptying secondary to anastomotic stricture, but no pancreatic complications. At a median follow-up of 47 months, three patients had died of recurrent disease while the other 10 were alive and well with no upper gastrointestinal symptoms. CONCLUSIONS: Provided there is a minimum 1-cm clearance at the papilla, PSDD is a useful alternative to formal pancreatoduodenectomy in patients with unusual neoplasms arising from the third and fourth parts of the duodenum. Although a major undertaking in its own right, it avoids the extra time of a pancreatic resection and the extra risk of a pancreatic anastomosis.

Ghrelin does not stimulate food intake in patients with surgical procedures involving vagotomy.

CONTEXT: Patients with gastric or esophageal surgery and transection of the vagus nerve may suffer from appetite and weight loss but without dysphagia or mechanical obstruction to eating. The gastric hormone ghrelin stimulates food intake and GH release in rodents and man. However, rodents with vagotomy are not sensitive to the feeding effects of ghrelin. OBJECTIVE: The objective of the study was to determine whether humans with vagotomy are sensitive to ghrelin. STUDY DESIGN: The design was a double-blind, randomized, placebo-controlled trial. SETTING: This was a hospital-based study. PATIENTS: Six men and one woman who all had a previous complete truncal vagotomy with lower esophageal or gastric surgery entered and completed the study. INTERVENTION: Each patient received 120-min infusions of saline, 1 pmol/kg.min ghrelin, and 5 pmol/kg.min ghrelin on 3 separate days. After 90 min, a buffet meal was served. MAIN OUTCOME MEASURE: Energy intake at the buffet meal was measured. RESULTS: Ghrelin-stimulated GH release in a dose-dependent manner was measured, confirming bioactivity. However, no change in energy intake was observed with either dose of ghrelin [energy intake (kilojoules): saline 2805 +/- 812; ghrelin 1 pmol/kg.min, 2486 +/- 767; ghrelin 5 pmol/kg.min, 2382 +/- 543; P = not significant]. CONCLUSIONS: Ghrelin is unlikely to be an effective appetite-stimulatory treatment for patients with vagotomy and esophageal or gastric surgery. Our results suggest that an intact vagus nerve may be required for exogenous ghrelin to increase appetite and food intake in man.

Advantages of laparoscopic stented choledochorrhaphy over T-tube placement.

BACKGROUND: Postoperative complications after laparoscopic choledochotomy are mainly related to the T tube. Both laparoscopic endobiliary stent placement with primary closure of the common bile duct (CBD) and primary closure of the CBD without drainage have been proposed as safe and effective alternatives to T tube placement. METHODS: This was a retrospective analysis of data collected prospectively on 53 consecutive patients suffering from proven choledocholithiasis who underwent laparoscopic CBD exploration through a choledochotomy between January 1999 and January 2003. In the early period a T tube was placed at the end of the procedure (n = 32). Biliary stent placement and primary CBD closure was performed from June 2001 (n = 21). RESULTS: There were no significant differences in epidemiological characteristics, preoperative factors or intraoperative findings between the groups. Seven patients developed complications, six in the T tube group and one in the stent group. Univariate analysis revealed a significantly lower morbidity rate and shorter postoperative hospital stay in the stent group. CONCLUSION: Placement of a biliary endoprosthesis after laparoscopic choledochotomy achieves biliary decompression, and avoids the complications of a T tube, leading to a shorter postoperative hospital stay. The method is a safe and effective alternative method of CBD drainage after laparoscopic choledochotomy.

A technique for safe placement of a biliary endoprosthesis after laparoscopic choledochotomy.

BACKGROUND: Biliary endoprosthesis has been proposed as an alternative to T-tube placement after laparoscopic choledochotomy in an attempt to eliminate the complications associated with T-tubes. Biliary endoprostheses have been, until now, placed under fluoroscopic guidance. We present a modification of Gersin's method for endoprosthesis placement under direct vision. PATIENTS AND METHODS: As of July 2001, seven patients who fulfilled the criteria for common bile duct (CBD) exploration through a choledochotomy, a biliary endoprosthesis was inserted under direct vision at the end of the procedure with primary closure of the CBD above it. In all cases, plastic biliary stents 10F in diameter were used ranging from 5 to 10 cm in length. We describe in detail the technique of CBD stent placement using the choledochoscope as the advancing device. We also propose the use of intraoperative cholangiography instead of on-table endoscopy to check the final correct position of the stent. RESULTS: The median postoperative hospital stay was 2 days. Two patients developed transient hyperamylasemia in the immediate postoperative period. None of the patients developed short-term complications (<30 days), namely bile leak, CBD erosion, stent occlusion, or stent migration. The long-term results revealed early return to full daily activities and normal liver function tests. Stents were removed endoscopically 4 weeks after the initial procedure except in two patients who spontaneously passed them. CONCLUSION: We propose a 10F 10-cm biliary endoprosthesis placed under direct vision as a safe, effective, time-sparing, and cost-effective adjunct to CBD exploration through a choledochotomy. Placement of the endoprosthesis is associated with low morbidity and eliminates the complications related to T-tubes.

Tuberculosis of the pancreas diagnosed with needle aspiration.

Tuberculosis of the pancreas is very rare and can present with many signs and symptoms, including obstructive jaundice, weight loss and a mass in the head of the pancreas. Hence the diagnosis of pancreatic tuberculosis remains a challenge and a high index of suspicion is required. If a tumour is suspected then an ultrasound- or CT-guided fine needle aspiration should be performed. Even if the initial microbiological results are negative, using conventional techniques, PCR can yield more rapid results and avoid an unnecessary laparotomy.

Liver resection in advanced hepatocellular carcinoma.

BACKGROUND/AIMS: The aim of this study was to assess the results of major liver resection in patients with advanced hepatocellular carcinoma in terms of safety and survival. METHODOLOGY: The subjects of this study are 19 patients that underwent 24 resections for advanced (stage IV) hepatocellular carcinoma. Eighteen of these resections were performed for primary tumor and 6 were repeat resections. Nine patients presented without cirrhosis, 5 with cirrhosis, and 5 patients had the fibrolamellar variant of hepatocellular carcinoma. RESULTS: Hospital mortality was recorded in 1 case (5%). Morbidity was noted in 7(37%) cases. All patients with fibrolamellar variant of hepatocellular carcinoma are alive at 78, 41, 24, 12 and 9 months (P = 0.008), compared with a median survival of 18 and 9 months for the noncirrhotic hepatocellular carcinoma and cirrhotic hepatocellular carcinoma groups, respectively (P = 0.24). CONCLUSIONS: We conclude that an aggressive policy of major liver resection with vascular reconstruction was justifiable in patients with advanced fibrolamellar variant of hepatocellular carcinoma and in selected patients with noncirrhotic hepatocellular carcinoma, and of doubtful value in patients with cirrhosis.

Chronic pancreatitis.

Chronic pancreatitis causes destruction of the pancreatic gland which leads to diabetes and malabsorption. Its principal cause is alcohol abuse, and intractable pain is the main clinical feature. The incidence of pancreatic carcinoma is increased among patients with chronic pancreatitis.

A continuing role for surgical bypass in the palliative treatment of pancreatic carcinoma.

BACKGROUND: The use of palliative surgery for irresectable pancreatic cancer has been challenged by the advent of non-operative stenting, but it may still be appropriate for selected patients. METHODS: Single-loop biliary and gastric bypass was carried out in 56 patients (mean age 60 years) with carcinomas of the pancreatic head that were irresectable because of vascular invasion or distant spread. In 42 patients without a preoperative tissue diagnosis, ductal carcinoma was confirmed by biopsy of the primary (n = 20) or secondary (n = 22) tumour. Preoperative biliary decompression in 31 patients led to positive bile cultures in 22 of 24 patients sampled. RESULTS: There were no deaths in hospital or within 30 days. Complications in 20 patients (35%) included three biliary leaks, two of which required temporary percutaneous stents. The median postoperative hospital stay was 14 days. No re-operations were required before death, though 2 patients required percutaneous stenting of the biliary anastomosis for recurrent jaundice, 1 of whom had a radiation-induced stricture. The median survival was 6 (range 2-21) months. CONCLUSION: Combined biliary and gastric bypass can be carried out with reasonable safety and remains a useful option for patients with potentially resectable tumours and an anticipated life expectancy of at least 6 months.

Liver resection using total vascular exclusion, scalpel division of the parenchyma, and a simple compression technique for hemostasis and biliary control.

Recent improvements in perioperative morbidity and long-term outcome following liver surgery have led surgeons to attempt larger and more technically challenging liver resections. Total vascular exclusion (TVE) of the liver during resection has been proposed as a technique that will facilitate these difficult resections while minimizing blood loss. Total vascular exclusion is performed by obtaining complete isolation of the vascular pedicle of the liver. Once the hepatic vein is clamped, rapid resections may be performed with a loss of only the blood volume contained within the liver itself. Safe performance of total vascular exclusion of the liver requires a thorough understanding of hepatic anatomy, patient selection criteria, and the physiologic changes incurred by hepatic exclusion and subsequent ischemia and reperfusion. The following report discusses these issues, gives a detailed description of the steps involved in obtaining safe total vascular exclusion, and presents a technique using rapid parenchymal excision with a scalpel and capsular compression to obtain hemostasis and prevent bile leaks. We briefly discuss our experience with 144 consecutive resections in which this technique was used.